- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,059.20 / $1,473.01 / $1,473.01
| Professional | | $1,059.20 | $1,473.01 | $1,473.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,323.10 / $1,368.48 / $1,368.48
| Professional | | $1,323.10 | $1,368.48 | $1,368.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $712.05 / $712.05 / $712.05
| Facility | | $712.05 | $712.05 | $712.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,673.12 / $1,935.80 / $2,969.62
| Professional | | $1,673.12 | $1,935.80 | $2,969.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,473.01 / $1,473.01 / $1,473.01
| Professional | | $1,473.01 | $1,473.01 | $1,473.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,215.71 / $1,740.94 / $2,251.21
| Professional | | $1,215.71 | $1,740.94 | $2,251.21 |